Nokea
The nurse is caring for a preschool-age child whose grandparent died 3 days ago. Which intervention is inappropriate?
- A. Assign the same nurses and caregivers to the child each day
- B. Avoid mentioning the loved one's death in the child's presence
- C. Explain the importance of being with the child to the parents
- D. Schedule time each day for age-appropriate play
Correct Answer: B
Rationale: Avoiding discussion of the grandparent's death may confuse the child or hinder grieving. Open, age-appropriate communication supports emotional processing.
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The nurse is teaching an adult who has a broken ankle that has been casted how to climb stairs. The nurse knows that the client understands how to climb up stairs when she does which of the following?
- A. While bearing weight on the unaffected leg, the client moves the crutches up to the next step followed by the affected leg and then the unaffected leg.
- B. While bearing weight on the unaffected leg, the client moves affected leg to the next step followed by the unaffected leg and the crutches.
- C. While bearing weight on crutches, the client moves the affected leg to the next step followed by the unaffected leg and the crutches.
- D. While bearing weight on crutches, the client moves the unaffected leg to the next step followed by the affected leg and the crutches.
Correct Answer: D
Rationale: To climb stairs, weight is borne on crutches, moving the unaffected leg first, then the affected leg and crutches, ensuring stability and safety using the stronger leg.
The nurse is caring for a 4-year-old who was hospitalized with influenza. Which nursing action would be most effective to maintain psychosocial integrity?
- A. Encouraging use of puzzles for play
- B. Offering the child stacking blocks for diversion
- C. Providing crayons to draw noses on facemasks
- D. Suggesting that playmates visit the child
Correct Answer: C
Rationale: Drawing on facemasks is an age-appropriate, creative activity that promotes self-expression and reduces fear associated with medical equipment, supporting psychosocial integrity.
A client who has Type 1 diabetes mellitus is admitted for alcohol detoxification. A moderate sliding scale for insulin is ordered. How often should the nurse expect to take glucose levels?
- A. Every time medication is administered
- B. When the client is symptomatic
- C. Before meals and at bedtime
- D. Every two hours
Correct Answer: C
Rationale: Sliding scale insulin for Type 1 diabetes requires glucose checks before meals and at bedtime to adjust dosing, ensuring glycemic control.
A 14-year old with leukemia tells the nurse, 'All I really want to eat is frozen yogurt.' The nurse should:
- A. Explain the importance of eating a balanced diet
- B. Ask the dietician to talk with the client to find out which foods he prefers
- C. Ask the kitchen to send the yogurt
- D. Document the client's refusal to eat the diet as ordered
Correct Answer: C
Rationale: Providing the requested yogurt respects the client's preferences and encourages intake, which is critical in leukemia patients who may have reduced appetite.
A 6-year old is admitted with a diagnosis of childhood autism. Which behavior is most typical of the child with autism?
- A. A willingness to talk to strangers
- B. A disinterest in inanimate objects
- C. Engaging in ritualistic behavior
- D. A dislike of music
Correct Answer: C
Rationale: Children with autism often engage in ritualistic or repetitive behaviors, such as specific routines or movements, as a hallmark of the condition. Choice A is incorrect because children with autism typically have social communication difficulties and are less likely to engage with strangers. Choice B is incorrect as they may show intense interest in specific inanimate objects. Choice D is incorrect as music preference varies and is not a defining characteristic.